Presented by:
Ms. Elizabeth M.Sc (N)
Asst. Professor,
Dept of MSN
NNC, GNSU.

Brain

 Brain tumour is a collection, or mass,
of abnormal cells in Brain.
 Skull, which encloses the brain, is
very rigid, any growth inside this
restricted place can cause problems.
 When these tumors grow inside the
brain it increases intra cranial
pressure, which can cause brain
damage and may be even life
threatening.

Incidence & Prevelance
• Last year, 62,930 new cases were reorded in United states for adult brain tumors,
while for children 4,030 new cases for were recorded for the same period, of
which 2,880 children were under 15 year of age.
• White american > Black Americans
• In US, brain tumor typically occur in 2 distinct categories
Children aged 0-15years
Adults in there 5th to 7th decade
• Meningioma, a benign primary tumor - 33.8% of primary brain tumor,
Glioblastoma Multiforme, a malignant tumor - 17.1% of adult primary tumor
• The largest percentage of childhood tumor i.e. 17% located in frontal, parietal and
occipital lobe followed by cerebellum (16%) and Brain Stem (11%)

Distribution of all primary brain and CNS tumors

Tumors were classified into 2 categories :
1. Primary Brain Tumors
2. Secondary Brain Tumors

Primary tumors can be Benign or
Malignant.
Primary tumors originates in the CNS

Benign brain tumors - Charecteristics
• It doesnt contain cancer cells
• Usually, benign tumors can be removed and the rarely grow back.
• Benign brain tumors have an obvious border or edge.
• They dont spread to other parts of the body
• They don't invade tissues around them
• However, benign tumors can press on sensitive area of brain and can cause serious health
problems.
• Unlike benign tumor of other parts of the body, benign tumor of the brain are sometimes life
threatening.
• with time benign brain tumors can become malignant.

Malignant brain tumors - Charecteristics
– Also called Brain Cancer
– Most serious and often are threat to life
– It contain cancer cells
– Rapid Growth
– Invade or crowd nearby healthy brain tissue
– Cancer cell may spread to other parts of the brain or to the spinal cord
– rarely spread to other parts of the body.

Primary brain tumors named according to the type of cells or the part of the brain in
which they begin.
1. Gliomas
2. Astrocytomas
3. Glioblastoma Multiforme
4. Oligodendrogliomas
5. Ependymomas & Ependymoblastomas
6. Medulloblastomas
7. Meningiomas
8. Pituitary adenomas
9. Schwannomas
10.Primary CNS lymphoma

Grading

Secondary Brain Tumor
Secondary brain tumors also called as Metastatic Brain Tumor
originates from malignancies outside of the CNS and spread to the
brain, typically through arterial circulation.

Clinical Manifestation of

Diagnosis
• Medical History including the specific nature of S&S
• Neurological Examination - Testing of reflexes & assess visual,
cognitive, sensory, and motor function.

Tumor Imaging
It is classified into 3 categories
• Static Imaging
• Dynamic Imaging
• Computer Integration Imaging

Static Imaging
Static neurological imaging includes CT and MRI, which are
noninvasive techniques that provide accurate anatomical and functional
analysis of intracranial structures.

CT Scan
• To determine tumor size.
• Contrast enhancement helps to identify isodense tumor from surrounding
parenchyma, hypodense lesions in edematous areas, and optimal sites for tumor
biopsy.
• After surgical intervention, CT can be used to confirm the proper tissue biopsy
site and determine the success of tumor resection.
• To detect calcification and bony involvement.

MRI
• To detect & localizing tumor as well as evaluating edema,
hydrocephalus or hemorrhage.
• Contrast enhancement with gadolinium sharpens the definition of
lesion
• MRI enhanced with gadolinium can distinguish between edema and
tumor

Dynamic Imaging
It includes
• Positron emission tomography (PET)
• Single photon emission CT (SPECT)
• Magnetic Resonance Spectroscopy (MRS)
• Functional MRI

PET Scan
• It uses radioactive markers to measure glucose metabolism which is
useful to determine the grade of primary brain tumor.
• It also helps in study of metabolic effect of chemotherrapy, Radiation
therapy and steroids on the tumor.

SPECT Scan
• To assess cerebral blood flow and determining tumor location.
• It is used to identify high- & low- grade tumor to differentiate between
tumor recurrence and radiation necrosis.
• It is used pre-op with static imaging to localize highest metabolic area of tumor
for biopsy.

Magnetic Resonance Spectroscopy
• To measure the metabolism of brain tumors.
• It has been proved to differentiate successfully normal brain from malignant
tumor and recurrent tumor from radiation necrosis.
• It also has been used to document early treatment response and provide
information regarding histological grade of astrocytomas.

Magnetic resonance angiography (MRA)
It generates images of blood vessels without dye or ionizing radiation
to evaluate the blood flow and position of vessels leading to the brain
tumor.

Functional MRI
• To map cerebral blood flow at the capillary level.
• Its intended purpose is to provide information regarding the diffusion
of contrast into tumor, resulting in better resolution of tumor and
edema.
• It can also be used to identify tumor in motor, sensory, and language
areas of the brain

Computed Integration Imaging
• Computed integration imaging involves the simultaneous display of
images from different techniques in a single imaging system that is
transposed to a reference stereotactic frame.
• Combining tumor images from different modalities, including CT, MRI,
PET, and SPECT.
• This development has resulted in significant advances in stereotactic
biopsy, interstitial radiotherapy, and laser-guided stereotactic resection.
• It provides a safer, more accurate method of tissue acquisition and biopsy.
• A correct tissue diagnosis can be made in 95% of cases

Biopsy
• Surgical biopsy is performed to obtain tumor tissue as part of
tumor resection or as a separate diagnostic procedure.
• Stereotactic biopsy is a computer-directed needle biopsy. When
guided by advanced imaging tools, stereotactic biopsy yields the lowest
surgical morbidity and highest degree of diagnostic information.
• This technique is frequently used with deep-seated tumors in
functionally important or inaccessible areas of the brain in order to
preserve function.

Laboratory Diagnosis
• Perimetry is the measurement of visual fields used when evaluating tumors near the optic chiasm.
• Electroencephalography (EEG) is used to monitor brain activity and detect seizures
• Lumbar puncture is used to analyze CSF, which is useful in the diagnosis and detection of
dissemination of certain brain tumors.
• Audiometry and vestibular testing are useful for diagnosing tumors in the cerebellopontine angle.
• Endocrine testing is used to examine endocrine abnormalities with tumors in the pituitary gland
and hypothalamus.

Treatment
1.Traditional Surgery
2.Chemotherapy
3.Radiation Therapy
4.Stereotactic Radiosurgery

Traditional Surgery
Primary Goal : Maximal tumor resection with the least amount of damage to neural
or supporting structures.
Purpose
1. Biopsy to establish a diagnosis
2. Partial resection to decrease the tumor mass to be treated by other methods
3. Complete resection of the tumor
4. Provision of access for adjuvant treatment techniques.or adjuvant treatment
techniques.

Biopsy
• It is performed through open, needle, and stereotactic needle techniques.
• Open biopsies involve exposure of the tumor followed by removal of a sample
through surgical excision.
• Needle biopsies involve insertion a needle into the tumor through a hole in the
skull and the excision of the tissue sample drawn through the needle.
• stereotactic needle biopsies use computers and MRI or CT scanning equipment
to assisst in directing the needle into the tumor.

Partial & Complete Resections
• It is accomplished through craniotomy.
• Craniotomy involves removal of a portion of the skull and seperation
of the dura mater to expose the tumor.
• Stereotactic craniotomy uses technologyto guide neurosurgeon duing
the procedure.

Traditional Surgery
• Pre - op
• Intra - op
• Post - op
• Limitation

Preoperative Management
• Before surgery, clients are evaluated for general surgical risks and
the possibility of tumors in additional locations.
• Unless medically contraindicated, steroids & anticonvulsant
medications are administered before surgery

Intraoperative Management
• During surgery, precautions are taken to prevent an increase in edema
or ICP.
• Mannitol(vasodiuretic) & Hyperventilation is used to decrease ICP,
Steroid use is continued
• Antibiotics are administered to prevent infection.

Postoperative Management
• Patients are observed in an intensive care unit for at least 24 hours for possible
intracranial bleeding or seizures. Blood pressure is monitored continuously.
• Post-op these patients are more prone to DVT but due to the risk of intracranial
bleeding, acoagulants cannot be given so Compression stockings are used
prophylactically.
• Steroids are tapered in 5-10 days post-op.

Limitations
• Medical Complication such as Hematoma, Hydrocephalus, infection, infarction
from procedure.
• Complications resulting from GA
• Increased cost of hospital stay and surgical procedure.

Chemotherapy
• It can be used independently or as an adjuvant to surgery or radiation.
• Chemotherapy drugs impede cellular replication of the tumor cells, interfering with their
ability to copy deoxyribonucleic acid (DNA) and reproduce.
• Methotrexate (Highly neuro-toxic) is admnistered with Leucovorin (Antidote)
• Temozolomide is orally available chemotherapeutic agent for the Rx of Gliomas.
• The antiangiogenesis agent monoclonal antibody - Avastin (bevacizumab)
• Vascular endothelial growth factor (VEGF) is administered intravenously.

Radiation Therapy
• It can be used alone or in conjunction with surgery or chemotherapy to treat
malignant brain tumors.
• It is typically chosen as a treatment option for tumors that are too large or
inaccessible for surgical resection and to eradicate residual neoplastic cells after a
surgical debulking.
• This type of treatment includes the Gamma Knife, linear accelerators, and the
cyberknife.

Stereostatic Radiosurgery
Stereotactic radiosurgery is used to treat benign and malignant tumors, vascular
malformations, and functional disorders. The primary modes of administration for
stereotactic radiosurgery include the Gamma Knife, linear accelerators, and the
cyberknife
The Gamma Knife is typically used for deeply embedded small tumors that require
precise delivery of radiation.
Linear accelerators used for conventional radiation can be modified for stereotactic
radiosurgery. The brain lesion to be targeted is stereotactically placed in the center of
the arc of rotation of the machine. A single, highly focused beam of radiation is delivered
over multiple sweeps around the brain lesion. Linear accelerators can be used to treat
larger tumors with precise shape while maintaining uniform dose.

Cyberknife
• The Cyberknife uses a compact linear accelerator mounted on a robotic arm, with
the robotic arm moving around the linear accelerator to multiple precalculated
positions.
• At each position the accelerator fires a beam of radiation at the tumor or lesion.
• A high cumulative dose of radiation is achieved at the tumor or lesion because of
the convergence of the beams.
• This dose is typically strong enough to destroy the abnormal cells while
minimizing the damaging effects of radiation to healthy surrounding tissue.

Rehabilitation
Rehabilitation can be a very important part of the treatment plan. The goals of
rehabilitation depend on needs and how the tumor has affected patients ability to
carry out daily activities.
Several types of therapists can help
1. Physical Therapists
2. Speech Therapists
3. Occupational Therapists